Assessing Option B+ retention and infant follow-up in Lilongwe, Malawi

Abstract

Malawi launched Option B+, a program for all pregnant or breastfeeding HIV-positive women to begin lifelong combination antiretroviral therapy (cART), in July 2011. This study characterises a portion of the continuum of care within an antenatal setting in Lilongwe. Women testing HIV-positive and having a cART initiation record at Bwaila Antenatal Clinic from July 2013 to January 2014 were included. Using logistic regression models, we analysed relationships between maternal characteristics and return for infant testing. Among 490 HIV-positive women with a cART initiation record, 360 (73%) were retained at three months. Of these, 203 (56%) were adherent. Records of infant testing were located for 204 women (42%). Women who were not retained were less likely to have an early infant diagnosis record (aOR = 0.20; 95% CI: 0.10, 0.41). Among the women retained, there was a non-significant association between maternal adherence and infant testing (OR = 1.35; 95% CI: 0.89, 2.06). Women lost at earlier continuum stages, who are at higher risk for mother-to-child-transmission, were less likely to bring infants for testing. Even with a test-and-treat program, many women did not remain in care or bring their infant for testing. Facilitating strategies to improve these measures remains an important unmet need.

Keywords: Africa; Human immunodeficiency virus; highly active antiretroviral therapy; prevention; women.

Figure 1. Continuum of care diagram showing the number of women progressing to each step of the continuum

Figure 1 depicts the number and percentage of women progressing to each subsequent step along the continuum of care. Follow-up time has been determined relative to the time of cART initiation. Each black or grey bar represents the number of women remaining in care at a given point on the continuum. Percentages in parentheses express the number of women who progressed to a given point in the continuum of care as a percentage of the women who progressed to the previous step in the continuum. Percentages on the bar graph express the overall percentage of women who initiated cART that progressed to that point in the continuum.

Figure 2. Kaplan-Meier survival curve showing retention in care among all HIV-positive women who initiated cART

Figure 2 depicts the Kaplan-Meier survival curve showing retention in care for all women who initiated cART relative to the time of cART initiation. Women at risk after a given length of retention in care is defined as the number of women still recorded to be in care at that point. This graph reflects all abstracted follow-up data. Women who did not return following initiation were given a follow-up time of 1 month as they were provided with sufficient medication for that time period. This accounts for the dramatic drop off at 1 month. These are women without a return visit.